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Vitiligo: Patient stories, self-esteem, and the psychological burden of disease

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Vitiligo is a relatively common disorder that is characterized by depigmented patches of skin. Multiple studies characterize the overwhelming psychological burden that is experienced by many patients around the globe. This review examines personal patient stories and the impacts of age, culture, sex, race, and ethnicity in relationship to altered self-esteem and quality of life in patients who live with vitiligo.
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Original Research
Vitiligo: Patient stories, self-esteem, and the psychological burden
of disease
,
☆☆
P.E. Grimes, MD
a,b,
, M.M. Miller, BS
c
a
Vitiligo & Pigmentation Institute of Southern California, Los Angeles, CA
b
Division of Dermatology, David Geffen School of Medicine, University of California, Los Angeles, CA
c
Keck School ofMedicine, University ofSouthern California, Los Angeles, CA
abstractarticle info
Article history:
Received 4 October 2017
Received in revised form 23 November 2017
Accepted 23 November 2017
Keywords:
vitiligo
self-esteem
quality of life
pigmentation
stigmatization
Vitiligo is a relatively common disorder that is characterized by depigmented patches of skin. Multiple
studies characterize the overwhelming psychological burden that is experienced by many patients around
the globe. This review examines personal patient stories and the impacts of age, culture, sex, race, and eth-
nicity in relationship to altered self-esteem and quality of life in patients who live with vitiligo.
© 2017 The Authors. Published by Elsevier Inc. on behalf of Women's Dermatologic Society. Thisis an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Vitiligo is an acquired disorder of pigmentation that is characterized
by depigmented patches of skin due to the loss of melanocytes.
Depigmented patches may appear in a localized or very generalized
distribution. Vitiligo affects 1 to 2% of the global population with an
equal incidence in male and female patients and in all racial/ethnic
groups (Grimes, 2016a). Multiple theories have been proposed
regarding the pathogenesis of this disorder (Harris, 2017). Current
data suggest that vitiligo results from the complex interplay of genet-
ics, oxidative stress, and autoimmunity (Grimes, 2016a). Recent
studies document the role of CD8 lymphocytes and the interferon-γ
CXCL10 cytokine signaling pathway in mediating the destruction of
melanocytes in patients with vitiligo (Harris, 2017).
Therapies for vitiligo address the stabilization of the disease as
well as the repigmentation of depigmented patches. Therapies that
affect disease progression include systemic steroid medications, oral
mini-pulse corticosteroid therapy, minocycline, and methotrexate.
First-line therapies for repigmentation include topical corticosteroid
medications, calcineurin inhibitors, and narrowband ultraviolet B
phototherapy (Grimes, 2016b).
Many global cultures and societies place a profound signicance
on appearance, esthetics, and pigmentation. Any condition that affects
appearance may be fraught with loss of privilege, opportunities, and
often upward societal mobility (Grimes, 2008). Given the inherent
visibility of skin disorders, self-esteem is often compromised. The
feeling of being ugly or undesirable has been described in patients
with a myriad of cutaneous diseases that range from acne to alopecia
areata to vitiligo. Skin disorders that negatively alter appearance have
the potential to affect an individualscareeraswellaspersonaland
social interactions. This effect on self-esteem and perception of beauty
transcends race, age, sex, and socioeconomic status. Societies that
have a cultural preference for specic skin tones often perceive
pigmentation as a passport to society, and perceived defects are
often devastating (Grimes, 2008).
Multiple studies have documented the psychological devastation
that is inicted by vitiligo. The seminal study by Porter et al. (1979)
documented the negative impact of vitiligo on patientsself-esteem.
The authors reported that patients who had lower self-esteem coped
poorly with the disease, but patients with higher self-esteem coped
better. Subsequent global studies have consistently reported the
negative impact of vitiligo on patientsself-esteem and quality of life
(QoL). Vitiligo causes isolation, stigmatization, loss of self-esteem,
International Journal of Women's Dermatology 4 (2018) 3237
Sources of support: None.
☆☆ Conicts of interest: The authors have no conicts of interest to disclose.
Corresponding Author.
E-mail address: pegrimesmd@aol.com (P.E. Grimes).
https://doi.org/10.1016/j.ijwd.2017.11.005
2352-6475/© 2017 The Authors. Published by Elsevier Inc. on behalf of Women's Dermatologic Society. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Contents lists available at ScienceDirect
International Journal of Women's Dermatology
depression, and self-consciousness. Herein, we highlight several
patientspersonal experiences in coping with vitiligo and review the
psychological impact of this traumatic disease.
Patient stories
Subject 1: 13-year-old Hispanic female patient (Skin Type IV)
I was about 6 years old when I found out I had vitiligo. At rst, I didnt
know what it was but I quickly learned. When I was growing up, I didnt
care what I looked like. Then, I switched schools and I didntknowwhat
kids at school would say or think of me. However, they quickly learned
and they accepted me for me. They dont care what I look like, which
makes me feel happy. When Im not at school, I will have my moments
when I start to cry and tell myself horrible things like Imugly,”“what
did I do to deserve this,and Im a horrible person.I know my family
loves me for me, but sometimes it doesnt feel like enough. Now that
Imenteringmyteenyears,Ive started to care more about my self-
appearance and self-esteem. I dont feel pretty with my spots. Sometimes
I wish I could go back to my younger self [who] didntcare.Ilookat
pictures of myself without spots and say to myself, Wow, I didnt
remember what certain parts of my body looked like and now they
look very different.I know my teen years will be very different and I
will need to turn to my family and friends for support.
Subject 2: 50-year-old African-American male patient (Skin Type VI)
I knew it was going to be a problem when I just nished lunch with a
friend and she said, You have something on the side of your mouth.
I was working at WABC TV in New York City as the entertainment
reporter. I had gone to the MTV Awards. I saw Michael Jacksonsperfor-
mance on stage. Earlier in the week, I interviewed Whoopi Goldberg for a
reprise ofa one-woman show. I was 26, in the biggest city, at thebiggest
station, and on the top-rated newscast. AND THERE WASNTANYFOOD
ON MY MOUTH! It was my skin.
I had been able to cover the small spots on my hands and scalpand
the one small spot just under my nose. But after eating, the corners of my
mouth could not be hidden. I thought the life I had created was over. I
didnt know how to react. And with time it got much worse. My Emmy
Award winning face was gone. I was a splotchy mix of black and white.
And I went through some stages: grief, fear, grief, anger, grief, and accep-
tance. And let me be clear. ITS BEEN YEARSof questioning, emotional
struggle, and crazy looksbut the truth is a little shocking. This disease has
become my blessing.
My name is LT, and I am an entertainment reporter/host in Detroit. I
travel the world covering entertainment. I am also thankful to be an
advocate for people like me. And I dont just mean people whose skin
changes so drastically people question if they should shake your hand
or hug you. I mean people who are struggling to exist comfortably and
lovingly in their own bodies.
Vitiligo can be a challenge but I have found support and guidance
leading to pride for my skin. I have created a life of my own denition.
And now, I cant imagine my journey any other way. I have become a
more loving and compassionate man. I am embracing the stares and
directing the attention, when appropriate, to positive ends.
How do I live with vitiligo? I LIVE! Oh, and by the way, I have vitiligo.
Subject 3: 62-year-old Caucasian female patient (Skin Type II)
Born with a bathing trunk melanocytic nevus, all my life Ive been
self-conscious about my skin. Finding a one-piece bathing suit to cover
my ank, back, and right upper thigh wasnt possible, but I imagined
that the patches of brown that peeked out didnt show. No such luck in
locker rooms where, fully naked, I heard taunting as a child and gasps
as an adult. I preemptively warned medical professionals after hearing
the question Have you been beaten?too many times.
But nothing prepared me for the white patches that suddenly emerged
in my thirties and that now, in my sixties, cover large areas of my body
and face. You would be wrong to assume that as a white woman, patches
of nonpigmented skin arent noticeable or that they dont provoke
anguish. Perhaps if I were alabaster white, Id feel differently, but I think
not. To lose color is to be a pale reection of ones former self, to lose
vividness and vitality. Moreover, in my case, vitiligo is likely a result of
my nevus, of my body killing its own melanocytes like Pac-Man scram-
bling to kill the ghosts before they kill him. In my twenties, I was told for
the rst time that my nevus could kill me. Vitiligo proves the point.
I know that vitiligo is a far greater cosmetic afiction for black and
brown people. In fact, I feel guilty for complaining or becoming distressed
when people say, But I cantseeit.Though often said with good inten-
tions, such dismissals compound my distress because they gaslight me
and incite guilt. Besides, it is noticeable. Ask the gastrointestinal doctor
who pointed it out to his students when trying to gure out why I perforat-
ed my colon. Ask the cosmetician trying to sell me foundation not knowing
which skin color she should match. Imbrave.Iactlikeits nothing, just as I
learned to do with my nevus. Then I go home. And then I cry.
People with skin conditions and perhaps other autoimmune disorders
often feel tremendous guilt. Have we caused our lesions because our
emotions are intense, because were angry, because we canthandlethe
normal stresses of life? Has it spread because we dont meditate or do
yoga or eat enough kale? John Updike called psoriasis, a condition he
hid for much of his life, a dermal sin to which he had to confess. Never
mind that we control very little in our lives, our culture demands, indeed,
runs on the illusion that we have control if only we would seize it.
Incurable and unpredictable, vitiligo could not have provided a more
perfect spur to the anxiety and depressive disorders Ive had to manage
since childhood. My clothes can no longer hide my skin disease. My
skin has become a living metaphor.
But meet me on the street tomorrow and youll never know that Im
hopeless or hiding. Be a y on the wall in my wonderful dermatologists
ofce and youll hear me tearfully confess my dermal sins and, perhaps,
decide to begin treatment anew. Because when your doctor has a great,
big soul, you too might say to yourself, why not? Why not keep trying?
These stories are profound personal narratives of stigmatization,
loss of self-esteem, emotional traumas, grief experiences, and coping
strategies. They reect and provide a cross-cultural, multi-ethnic, age,
and sex perspective of the burden of disease (Figs. 1, 2, and 3).
Impact of sex, culture, and race/ethnicity
The impactof vitiligo on patientsQoL has been assessed in global
populations, and the outcomes vary. However, most results substan-
tiate the negative impact of the disease on patientsQoL (Table 1;Bae
et al., 2017; Belhadjali et al., 2007; Bhandarkar and Kundu, 2012;
Borimnejad et al., 2006; Boza et al., 2016; Chan et al., 2013; Elbuluk
and Ezzedine, 2017; Ezzedine et al., 2015, 2015; Ingordo et al.,
2014; Kiprono et al., 2013; Komen et al., 2015; Ongenae et al., 2005;
Parsad et al., 2003; Radtke et al., 2009; Silverberg and Silverberg,
2013; Talsania et al., 2010; Teovska Mitrevska et al., 2012).
In a large study of 1541 patients, the authors evaluated the associa-
tions among vitiligo extent, distribution of disease, and QoL impair-
ment. Vitiligo had indeed a negative impact on total Dermatology Life
Quality Index (DLQI) scores. Scores were signicantly associated with
an affected body surface area (BSA) of greater than 25% and body
parts affected (Silverberg and Silverberg, 2013). Eighteen percent of
patients reported sexual dysfunction, with equal frequency in male
and female patients, which correlated with the presence of genitalia le-
sions. In contrast, other studies have reported greater sexual dysfunc-
tion in female patients compared with male patients (Borimnejad
et al., 2006). In an Italian population of 161 patients, although vitiligo
33P.E. Grimes, M.M. Miller / International Journal of Women's Dermatology 4 (2018) 3237
had only a mild impact on QoL, DLQI was signicantly associated with
female sex and facial involvement at the time of the onset of the
disease.
Several studies have compared the QoL of patients with vitiligo to
that of patients with other chronic dermatological diseases such as
psoriasis. Porter et al. (1986) and Ongenae et al.(2005) both reported
higher DLQI scores in patients with psoriasis overall. However, in the
study by Porter et al. (1986), self-esteem measures did not differ. In
contrast, Ongenae et al. (2005) reported that although women with
vitiligo and psoriasis had comparable scores, men with vitiligo had
signicantly lower DLQI scores compared with men with psoriasis,
which again indicates a sex divide in coping with the disease.
Myriad authors have reported a relationship between culture and
the psychological burden of vitiligo. Historically, patients in India
experience psychological trauma and stigmatization. In the Indian
book Rigveda, a person who suffers from Switra (vitiligo) and the
persons progeny are disqualied from marrying (Elbuluk and
Ezzedine, 2017; Ezzedine et al., 2015, 2015). The psychological burden
of the disease is profound for young, unmarried women. Given the
systems of arranged marriages, vitiligo lessens the possibilities for mar-
riage. Moreover, in married women who develop vitiligo, the disease
increases the possibility of divorce. Finally, patients in India with high
DLQI scores did not respond as well to therapies for repigmentation,
which suggests that psychological intervention should be included in
the hierarchy of therapies for vitiligo (Parsad et al., 2003).
Thompson et al. (2010) interviewed seven South Asian women
who lived in the United Kingdom and analyzed their data with a
qualitative method of template analysis. All women experienced
stigmatization, which was often associated with cultural values that
are related to appearance and myths of vitiligo. One woman stated,
My grandma (in Pakistan) was like, Oh you cant take her with
you (to visit friends and family) because of her skin, what will other
people say?’”
The assumption is often made that the psychological burden of
vitiligo is greater in racial/ethnic groups with darker skin. A recent
survey stratied 300 patients by skin phototype, including 234 pa-
tients with fair skin and 66 patients with dark skin. The patients
with darker phototypes were of Caribbean, South Indian, or Middle
Eastern ancestry. Even though the dark skin phototypes perceived a
signicantly greater difference in the burden of vitiligo on daily life,
overall self-perceived stress that was associated with vitiligo was
similar regardless of the skin type (Ezzedine et al., 2015, 2015). In
contrast, Porter and Beuf (1991) studied vitiligo in 158 patients and
Fig. 1. Depigmented patcheson the trunk and axillary regionof a 52-year-old African-
American female patient
Fig. 2. Extensive depigmented patches on the back of a 48-year-old Hispanic female
patient
Fig. 3. Severe depigmented patches on the trunk of a 9-year-old Caucasian female
patient
34 P.E. Grimes, M.M. Miller / International Journal of Women's Dermatology 4 (2018) 3237
found no differences in the degree of disturbance of vitiligo in
African-American and Caucasian patients. Even though both groups
were affected negatively by the disease, self-esteem and perceived
stigmatization of vitiligo were similar. These ndings raised the
possibility of different support networks and resources that may
affect African-American patientscoping skills for vitiligo (Porter
and Beuf, 1991).
Anatomic involvement
As noted, studies have reported that a greater extent of BSA
involvement has a correlation with a more severe impact on patients
QoL (Silverberg and Silverberg, 2013). In addition, multiple studies
have found that lesions that affect more visibly prominent areas
such as the face and hands and more sensitive areas such as the
genitalia have a more severe impact on patientsQoL.
Patients with involvement in unexposed genital areas often do not
report these lesions to healthcare providers out of embarrassment or
even stigmatization that this could be related to a sexually transmitted
disease. Genital involvement and generalized vitiligo are signicant
risk factors that affect patientssexual lives (Cupertino et al., 2017). In
a study of 167 patients, 14% had vitiligo patches in their genital area;
of those, 21.6% reported that vitiligo negatively affected their sexual
relationships (Kim et al., 2013). Talsania et al. (2010) found that 56%
of survey respondents reported genitalia involvement, which is a
much higher number than previously reported. The authors also
found that 76% of survey respondents had facial involvement and
considered this to be more disguring, with 56.6% of respondents
classifying the effect on theirQoLasmoderatetosevere.
Impact on children
Children comprise 25 to 38% of patients with vitiligo (Grimes,
2016a). Several studies have addressed QoL impairment in children
with vitiligo. Boza et al. (2016) assessed QoL in a series of adults
with the Vitiligo Quality of Life Assessment (VitiQol) and the DLQI
Table 1
Review of various studiesin the literature that chronicle the extent vitiligo on QoL in different countries and patient populations
Title of study Country Number of subjects Skin phototype DLQI score (SD) Comments
Living with vitiligo, results form a
national survey indicate differences
between skin and phototypes (2015)
France 300 (216 F, 82 M) Fair (n = 234)*; Dark
(n = 66)** *Fitzpatrick
I-III, **Fitzpatrick IV-VI
Fair: 8.3 (6.2);
Dark: 10.1 (6.1)
Patients with darker skin type reported
statistically signicant (p= 0.049)
higher DLQI scores
Investigating factors associated with
depression of vitiligo patients in
Singapore (2013)
Singapore 222 (115 F, 105 M) Not assessed 4.0 (4.4) Female patients reported statistically
signicantly higher DLQI scores, 4.8
(5.1) vs. 3.2 (3.2), respectively.
Quality of life in family members of
vitiligo patients: A questionnaire study
in Saudi Arabia (2013)
Saudi Arabia 148 (72 F, 69 M) Not assessed 9.0 (6.5) Family DLQI was measured and found
to be 10.3.
To what extent is quality of life impaired
in Vitiligo? A multicenter study on
Italian Patients using the DLQI (2014)
Italy 161 Not assessed 4.3 (4.9) More severe QoL impairment was
associated with the female sex.
Association between vitiligo extent and
distribution and quality of life
impairment (2013)
United States of
America
1541 (1080 F, 433 M) Not assessed 5.9 (5.5) Affected BSA N25% was correlated
with signicant QoL impairment.
Factors affecting the quality of life in
patients with vitiligo: A nationwide
study. (2017)
Korea 1123 (514 F, 609 M) Not assessed DLQI not used Skindex-29 usedas a QoL
measurement. Larger BSA involvement,
involvement of visible body parts and
higher educational level were all
associated with larger QoL impairment.
Quality of life impairment in children and
adults with vitiligo: A cross-sectional
study based on dermatology-specic
and disease-specic quality of life
instruments. (2017)
Brazil 117 (75 F, 42 M) Not assessed 3 Women had statistically higher DLQI
scores than men (3.0 vs. 2.0,
respectively).
Quality of life with vitiligo: Comparison
of male and female Muslim patients in
Iran. (2006)
Iran 77 (53 F, 24 M) Not assessed DLQI not used Modied DLQI used, women with
vitiligo experienced signicantly
lower QoL compared with men.
Dermatology Life Quality Index score in
vitiligo and its impact on the treatment
outcome. (2003)
India 150 (83 F, 67 M) Not assessed 10.7 (4.6) No statistical signicant difference in
DLQI scores related to sex. Age of
vitiligo subjects and DLQI scores were
correlated.
Quality of life of patients with vitiligo
attending the Regional Dermatology
Training Center in Northern Tanzania.
(2013)
Tanzania 88 (52 F, 36 M) Not assessed 7.2 (4.8) Female sex, BSA affected and previous
treatments were statistically
signicantly associated with higher
DLQI scores.
Willingness-to-pay and quality of life in
patients with vitiligo. (2014)
Germany 1023 (731 F, 292 M) Not assessed 7.0 (5.9) Female patients experienced higher
DLQI scores (7.0) versus male patients
(5.5).
Vitiligo and quality of life: A case control
study. (2007)
Tunisia 60 (30 F, 30 M) Not assessed 9.4 (4.1) Quality of life was signicantly more
impaired in female patients and in
cases with more than 10% BSA
involvement.
Vitiligo is more than skin deep: A survey of
members of the Vitiligo Society. (2010)
United Kingdom 520 (354 F, 166 M) Not assessed DLQI not used Participants could classify their vitiligo as
having a major, moderate, minor, or
trivial effect on their QoL. A total of 86
patients (16.6%) rated the QoL effect as
major, 206 patients (40.2%) as moderate,
152 patients (29.7%) as minor, and 50
patients (9.8%) trivial.
BSA, body surface area; DLQI, Dermatology Life Quality Index; F, female; M, male; QoL, quality of life; SD, standard deviation
35P.E. Grimes, M.M. Miller / International Journal of Women's Dermatology 4 (2018) 3237
and in pediatric patients using the Childrens Dermatology Life
Quality Index (CDLQI) and found a signicant correlation between
age and CDLQI score in children. In another study, the QoL of 50
children with vitiligo was compared with 50 children with atopic
dermatitis and healthy controls who were matched for age and sex.
Patients with vitiligo had signicantly higher CDLQI scores compared
with healthy controls. CDLQI scores were also signicantly increased
compared with those of patients with atopic dermatitis except in the
parameters of pruritus and sleep (Dertlioğlu et al., 2013).
QoL assessed by the CDLQI was examined in 24 boys and 50 girls
with matched controls for sex and skin type. Even though the QoL
in the patients with vitiligo was not signicantly impaired, they
reported a spectrum of negative experiences. Sixty-six percent of
patients were distressed by their disease, and 92% had experienced
low-key stigmatization (Krüger et al., 2014).
Silverberg and Silverberg (2013) performed an online, parental,
questionnaire-based study of 350 children ages 0 to 17 years using
the CDLQI and showed that vitiligo negatively affected CDLQI scores.
The most bothersome sites for children and their parents were the
face and legs. A BSA greater than 25% was associated with self-
consciousness, fear, and bullying. Teenagers ages 15 to 17 years
experienced the most self-consciousness of all pediatric age groups
(Silverberg and Silverberg, 2013). Another study reported that, in
general, social and psychosocial development and general health-
related QoL in young adult patients with childhood vitiligo were not
different from those of healthy controls. However, patients who
reported negative childhood experiences had signicantly more
problems in social development as adults compared with those
with positive experiences (Linthorst Homan et al., 2008).
As with adults, these studies suggest that children experience
substantial trauma related to vitiligo.
Effects of disease on family members
Several studies have assessed the QoL of family members of pa-
tients with vitiligo. One report in the literature studied 50 families of
children with vitiligo and 50 families of healthy children. The
psychological impact of the disease on parents was measured using
the Self-Rated Health Measurement Scale (SRHMS) and the Dermatitis
Family Impact (DFI) questionnaire. SRHMS scores for parents of
children with vitiligo were signicantly lower than for parents with
healthy children, and mean DFI scores in affected families were higher.
The ndings suggest that parents of children with vitiligo suffer
signicant psychological trauma and an altered QoL. The impact on
mothers of children with vitiligo was greater compared with fathers
(Amer et al., 2015).
Another study assessed the QoL of family members of patients
with vitiligo in Saudi Arabia. Data were collected for 141 patients
along with their family members over age 18 years who were living
in the same household. Validated QoL questionnaires included the
DLQI and the Family Dermatology Life Quality Index (FDLQI). Family
membersQoL was negatively impacted in 91.5% of cases. Hence,
vitiligo had a major impact on the QoL of family members of patients.
The most affected FDLQI that was reported by the authors, in order of
decreasing frequency, were emotional impact, burden of care,impact
on the physical wellbeing of family members, reactions of others in
response to the patients appearance, and effect on social life (Bin
Saif et al., 2013).
Intervention strategies
Many clinical trials and reviews do not address QoL as an outcome
measure, despite overwhelming evidence of the psychological bur-
den of vitiligo. A study published in 2012 found that repigmentation
was the most common outcome measured in clinical trials (96%) and
only 9% of clinical trials had assessed QoL outcomes. The authors
proposed that future clinical trials address the following items in
addition to repigmentation: cosmetic acceptability of results, global
assessment of the disease, QoL and maintenance of repigmentation,
stabilization of disease, and medication side effects (Eleftheriadou
et al., 2012).
There is indeed a dearth of literature that addresses the need for a
spectrum of intervention approaches to improve the psychological
burden of vitiligo. In a study of 53 patients in India, major depressive
disorder was reported in 57% of patients, social phobia in 68%, and
suicidal ideation in 28% (high risk 8%; low risk 21%). These ndings
stress the need for psychological and/or psychiatric intervention
(Ramakrishna and Rajni, 2014). Papadopoulos et al. (Papadopoulos
et al., 1999) reported that counseling and cognitive behavioral therapy
could improve self-esteem, body image, and overall QoL in patients
with vitiligo.
Cosmetic camouage was recently shown to improve the QoL of
children with skin disorders. Twenty-two children with different cuta-
neous disorders were studied, of whom eight had vitiligo. The authors
found that there was a statically signicant reduction in CDLQI and
FDLQI scores with cosmetic camouage (Salsberg et al., 2016).
Conclusions
Vitiligo is one of the most psychologically devastating diseases in
dermatology because of the global paradigm of pigmentation as a pass-
port to society in many cultures. Although the contrast of depigmented
patches is most visible in racial/ethnic groups with darker skin, all pa-
tients with vitiligo experience some degree of emotional devastation
that is caused by the disease. Physicians must have a heightened
awareness of the impact of vitiligo on self-esteem and QoL. Such
awareness and vigilance as clinicians in monitoring and addressing
the mental health needs of patients with vitiligo is crucial to optimize
patient care. Interventions should address dispelling myths that sur-
round vitiligo, including the notion that vitiligo is a cosmetic disease,
while offering or providing optimal therapies for repigmentation.
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... Given that stark contrasts between pigmented and depigmented lesions are more prominent in darker skin tones, vitiligo can be more socially stigmatizing and psychologically devastating in these patients. 4,5 Treatment of vitiligo includes narrowband UVB (NB-UVB) light phototherapy, excimer laser, topical corticosteroids, topical calcineurin inhibitors such as tacrolimus and pimecrolimus, and surgical melanocyte transplantation. 1 In July 2022, ruxolitinib cream 1.5% was approved by the US Food and Drug Administration (FDA) for nonsegmental vitiligo in patients ages 12 years and older. 6,7 It is the only FDA-approved therapy for vitiligo. ...
... 8 Vitiligo has a significant impact on the personal and social life of the affected individual due to cosmetic disfigurement. 9 The patient may suffer from embarrassment, discomfort, depression, and social isolation, and may go into hiding especially when the lesion appears on the exposed part of the body. This may ultimately impact the relationship with friends and relatives. ...
Article
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Background Vitiligo is a chronic dermatological condition associated with an increased risk of psychiatric disorders, including Suicidal Ideation (SI). Therefore, understanding of SI in patients with vitiligo is critically important. This systematic review aimed to investigate the assessment, and prevalence of SI in vitiligo patients. Method This systematic review was prepared according to the PRISMA statement. We searched PubMed, Scopus, Google Scholar, and additional sources to find out relevant articles. Study selection, data extraction, and quality assessment were carried out independently by two reviewers. We used the Joanna Briggs Institute critical appraisal checklist tool to assess the methodological quality of the included study. Findings Six studies involving 516 vitiligo patients were included in the analyses. The prevalence of suicidal ideation ranged from 6% to 25%. Two studies relied on 28 items General Health Questionnaire (GHQ) and the remaining studies used the Hamilton Rating Scale for Depression (HDRS), Beck Depression Inventory (BDI), Quick Inventory of Depressive Symptomatology- Self Report-16 (QIDS-SR-16) and Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Conclusion Clinicians should aware that a significant proportion of vitiligo patients are exposed to the risk of suicide. Therefore, it is recommended that vitiligo patients should be screened for suicidal ideation and make appropriate referrals to treat their psychiatric morbidities.
... Vitiligo is an acquired depigmentation disease resulting from the loss of epidermal melanocytes, and this cosmetically disfiguring problem causes great psychological and social effects in patients. 21,22 However, the management of vitiligo remains challenging, and a safe and effective treatment remains to be identified. 23 As recommended by current guidelines, 24-26 the treatment options for vitiligo include topical steroids, calcineurin inhibitors, vitamin D, Janus kinase inhibitors, laser therapy, and surgery. ...
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Objective Platelet-rich plasma (PRP) is a novel treatment option for vitiligo. PRP has been reported to be effective in combination with 308-nm excimer laser therapy, but there is no consensus on their combination use. Therefore, this meta-analysis assessed the efficacy and safety of the combination regimen in patients with vitiligo compared with laser therapy alone. Methods The meta-analysis was performed by searching PubMed, EMBASE, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, and WanFang to identify relevant publications published through 1 February 2022. Results Six studies involving 302 patients were included. Compared with phototherapy alone, combination treatment with PRP and 308-nm excimer laser therapy significantly improved the total response rate and reduced the no response rate. Additionally, the proportions of patients with repigmentation rates of ≥75%, ≥50%, and ≥25% were significantly higher in the combination group than in the monotherapy group. In addition, the rates of adverse events for combination therapy were comparable to those for laser therapy alone, and the recurrence rates were low. Conclusions This meta-analysis provided evidence supporting the combined use of PRP and 308-nm excimer laser therapy as a valuable treatment modality for patients with vitiligo based on its superiority to monotherapy.
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Background: Microneedling was initially introduced for skin rejuvenation. This review analyzes the current literature on microneedling techniques, efficacy, and safety for vitiligo treatment. Methods: An extensive PubMed search was performed to identify literature on microneedling therapy for vitiligo. Case reports, case series, and clinical trials were included. Results: All 14 articles evaluated showed improvement of lesions after microneedling treatment. Combination of microneedling and topical tacrolimus, 5-FU, topical calcipotriol and betamethasone, NB-UVB with or without PDT, and triamcinolone acetonide solution yielded more efficacy than microneedling monotherapy. Conclusion: Microneedling is a safe and efficient technique and an adjuvant treatment for vitiligo treatment.
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Chapter
The prevalence of metabolic syndrome is increasing day by day, owing to the sedentary lifestyle, unhealthy food habits, genetic factors, environmental influences and many other conspicuous variables. Skin, aptly considered to be a mirror of internal organs, often manifests with certain signs and symptoms, suggestive of a diagnosis of metabolic syndrome. In this chapter, we have attempted to touch upon the dermatological manifestations (both common and uncommon) of metabolic syndrome.KeywordsMetabolic syndromeDiagnosisSkin manifestations
Chapter
Dermatology specific quality of life measurement instruments like Dermatology Life Quality Index (DLQI) are used to quantify the impact of disease on patient quality of life, measure the effectiveness of treatment in improving the patient outcomes and have become an integral part of various studies and clinical trials. Various age- and disease-specific indices have been developed to measure impact of various dermatoses across different populations. Men and women perceive skin disease and its impact on life differently, perhaps due to societal and cultural factors, leading to significant differences between men and women in the DLQI of various dermatoses. Disease fluctuation due to hormonal changes in puberty, pregnancy and menopause also contributes to morbidity. Various dermatoses like vitiligo, hidradenitis suppurativa, psoriasis, acne and hirsutism have been associated with poorer quality of life in women compared to men.
Chapter
Vitiligo is a depigmentation disorder with a high psychological impact. It affects 0.5–2% of the population worldwide. Psychological comorbidities associated with vitiligo are feelings of stigmatization, adjustment disorders, sleep disturbance, relationship difficulties, including sexual dysfunction and avoidance or restriction behavior. Depression, anxiety, and alexithymia have been associated too and we have several studies in this way, they will be included in the chapter. Female sex, visible or genital lesions, age < 30 years, and greater body surface area involvement are risk factors to develop psychological comorbidities. Psychological test (HADS, TAS-20, DLQI, or BDI-II) could be useful to assess these patients and to decide the better therapeutical approach.
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Vitiligo is an autoimmune disorder, which is characterized by the chronic loss of melanocytes and subsequent lack of melanin from the skin or hair or both. The resultant depigmentation state of the skin causing irregular white patches deteriorates the vitiligo patients’ quality of life by major stigmatizing psychological impact. Despite tremendous studies for the past several decades, there has been a dearth of precise theranostics for vitiligo, which necessitates to revisit the molecular changes in vitiligo. Following advent of omics research, the examination of circulating non-coding RNAs including miRNAs has been enormously utilized for potential vitiligo therapeutic targets, however the expression profile of miRNAs and their target genes have not been studies at exosomal level in correlation with the differentially expressed genes (DEG) at the tissue level in vitiligo patients. Exosomes are tiny extracellular vesicles, with diameter approximately 30-200 nm, which is released from various cell types, and found in different biofluids including blood serum and plasma. Notably, the exosomes have been found to mimic the constituents of their parent cells, enabling it an excellent theranostics platform for diseased condition. Therefore, we investigated the plasma exosomal miRNA and identified the target genes associated with immune infiltration in vitiligo patients compared to healthy subjects. In this study, 65 DEGs have been analyzed by heatmap, among which 44 genes are up-regulated and 21 are down-regulated, which are associated with melanin- biosynthetic and metabolic process. CENPN and SLIRP were found to be substantially correlated with immune cells viz. CD8+ T cells, M1-macrophage. Among several target genes by the exosomal miRNAs, SLIRP has been found to be associated with miR-16-5p, whereas CENPN has been found to be associated with miR-6721-5p, and miR-486-5p. Conclusively, the exosomal miR-16-5p, miR-6721-5p, and miR-486-5p could be potential theranostics targets for vitiligo.
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Vitiligo is a chronic common skin disease. The asymptomatic hypopigmented cutaneous lesions are considered by many health care professionals as a cosmetic problem only; however, vitiligo can cause a major psychosocial impact in patients' lives. We review some of the factors responsible for this impact, such as the general public's wrong perception of the disease, feelings and emotional responses from patients, how stressful events can act as triggers of the disease, stigmatization experiences suffered by the patients, the prevalence of psychiatric morbidity, the effects on relationships and sex life, how quality of life in adults and children is impaired, and how treatment can improve it.
Article
In vitiligo, areas of skin lose their colour and become completely white. These white areas, which are often irregular like islands on a map, usually stand out against the normal skin around them, and are very obvious in individuals with a naturally pigmented (brown or black) skin, or in white-skinned people with a tan. People with vitiligo can become very embarrassed and withdrawn, not wanting to go out or to meet people; as a result, the quality of their day-to-day life can suffer. Vitiligo affects between 0.5% and 2% of the population and treatment does not work very well. This study from South Korea looked at what factors to do with vitiligo most affected patients’ quality of life. It was a large study involving more than 1,100 adults from 21 different hospitals. Patients filled in a detailed questionnaire called the Skindex-29 questionnaire and members of the study team examined the patients’ skin. From the questionnaire results, what concerned patients most were whether the vitiligo was going to get worse and whether it was a serious condition. They were also concerned about how loved ones felt about it, and over half the patients felt depressed about their condition. Involvement of large areas of the body, or areas of the body that other people could easily see, particularly affected quality of life. Vitiligo is far from just a cosmetic problem: over a third of patients were affected emotionally even if the areas of vitiligo were normally covered up.
Article
Background: Little is known about factors affecting the quality of life (QOL) of patients with vitiligo, and previous studies have shown conflicting results. Objectives: To explore QOL of patients with vitiligo and to identify factors affecting QOL. Methods: A nationwide questionnaire-based study was conducted with 1123 patients with vitiligo recruited from 21 hospitals in Korea from July, 2015 to June, 2016. Data were collected using a structured questionnaire for demographic information and the Skindex-29 instrument. Mild or severely impaired QOL in patients with vitiligo was assessed according to each arm (symptoms, functioning, and emotions) of the Skindex-29. Multivariate logistic regression analyses were performed to determine the factors associated with QOL. Results: The enrolled participants consisted of 609 males and 514 females with a mean age of 49.80 years (range, 20-84 years). The median duration of disease was 3.00 years (range, 0-60 years). Using multivariate logistic regression modeling, the involvement of visible body parts and a larger affected body surface area were consistently associated with QOL impairment in all three domains of the Skindex-29. Additionally, the QOL of patients aged 20-59 years, who potentially had a more active social life than older patients, was associated with functional impairment. In addition, a higher educational background was associated with emotional impairment. Conclusions: The multitude of factors significantly influence the QOL in patients with vitiligo. A better appreciation of these factors would help the management of vitiligo patients. This article is protected by copyright. All rights reserved.
Article
Vitiligo is a complex, systemic disease associated with many autoimmune and autoinflammatory conditions. Additionally, the cutaneous changes of vitiligo have significant effects on quality of life and self-esteem. Further efforts are needed to increase our understanding of vitiligo comorbidities as well as to increase awareness of the psychological effects of vitiligo.
Article
Background: Vitiligo can negatively affect a patient's quality of life (QoL). A specific questionnaire has been developed and validated in the English language: the vitiligo-specific quality-of-life instrument (VitiQoL). The instrument was translated, culturally adapted and validated into Brazilian Portuguese (VitiQoL-PB). Objective: The aim of this study was to assess the QoL in adult patients through the VitiQoL and Dermatology Life Quality Index (DLQI) and in pediatric patients through the Children's Dermatology Life Quality Index (CDLQI) in a sample of patients with vitiligo. Methods: Subjects were selected from a dermatological outpatient clinic and from a private practice in Porto Alegre. The QoL of pediatric patients was evaluated using the CDLQI questionnaire. In adult patients we used the VitiQoL-PB and the DLQI. Results: A strong correlation between the scores of the total VitiQoL and DLQI was observed (r = 0.81; p < 0.001). The factor that most contributed to the final score of VitiQoL was stigma. In our sample, women had higher scores than men (p < 0.05). Psychiatric problems were associated with lower QoL. In the pediatric population, the median score of the CDLQI was 3 (interquartile range 1.3-7.3). There was a statistically significant correlation between the child's age and the CDLQI score (rs = 0.41, p = 0.044). Conclusion: This study confirms that the VitiQoL is easy to administer and adds important information about the impact of vitiligo on a South American population. Stigmatization is very present in the disease. There are groups of patients that are more vulnerable, like women, patients with psychiatric diseases and adolescents.
Article
Cosmetic camouflage is known to improve quality of life in adults. Few data are available regarding cosmetic camouflage in children, and thus it is not often selected as a mode of treatment. We sought to determine whether cosmetic camouflage leads to improved quality of life of pediatric patients with visible dermatoses and their parent or primary caregiver. Patients aged 5 to 17 years with visible skin disease and their parent were assessed with the Children's Dermatology Life Quality Index (CDLQI) and the Family Dermatology Life Quality Index (FDLQI) before and after consultation regarding cosmetic camouflage. Twenty-two children with skin conditions were included in the study. The mean CDLQI decreased from 6.82 (SD = 1.28) to 3.05 (SD = 0.65; P = .0014), while the mean FDLQI decreased from 7.68 (SD = 1.15) to 4.68 (SD = 0.92; P = .0012). Our study highlighted improvement in quality of life in patients with skin disorders who were managed with cosmetic camouflage. © The Author(s) 2015.
Article
Although vitiligo impacts quality of life negatively, limited information exists regarding the overall vitiligo burden in different skin phototypes. We demonstrate that dark and light phototypes cope with vitiligo differently, although both are equally stressed. Improved understanding of the overall vitiligo burden may assist dermatologists to better target at-risk patients. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
Article
Background Vitiligo is a common depigmenting skin disorder that can influence a patient's quality of life. Although patient-orientated medicine is an emerging concept, a self-assessment tool to assess the degree of depigmentation in vitiligo is not yet available. Therefore, we developed the SAVASI, a self-assessment tool that uses the same basic principles as the VASI.Objective To assess the validity, reliability and acceptability of the SAVASI.Methods To assess the validity of the SAVASI, we compared the scores assessed by the patient with the scores of the VASI assessed by the physician. To assess the intra-rater reliability, the correlation between the baseline SAVASI and the SAVASI after 2 weeks was calculated. To assess the acceptability, patients indicated the time needed to complete the SAVASI and the patient assessed the difficulty of the questionnaire on a five-point scale. The Skindex-29 was used to determine the quality of life. The overestimation of the SAVASI compared to the VASI was calculated by subtracting the VASI scores off from the SAVASI scores.ResultsA high correlation between the VASI and the SAVASI (ICC 0.97, 95% CI: 0.95–0.98) was found in 60 patients. The intra-rater reliability of the SAVASI (ICC 0.75, 95% CI 0.54–0.87) was adequate in 31 patients. Fifty (83%) of the patients completed the questionnaire within 10 min and only five (8%) of the patients considered the SAVASI hard. We found no correlation between overestimation of the SAVASI score and the Skindex-29 score.Conclusion The SAVASI is a valid, reliable and acceptable self-assessment tool to measure the degree of depigmentation in vitiligo. With the SAVASI the degree of depigmentation can reliably be assessed by the patient themselves which can be useful in large (epidemiological) studies. Furthermore, this could contribute to the patient's disease insight and therapy loyalty.